Abstract
The implementation of electronic medical records (EMRs) represents one of the most significant changes taking place in the medical field today. The purpose of this Performance Improvement Patient Safety initiative was to evaluate and improve the documentation of c-spine clearances by standardizing the confrontational spine examination for patients sustaining blunt trauma using the EMR. A retrospective audit of trauma charts was performed over a 6-month period to evaluate c-spine clearance documentation. Following the initial audit, a strategy, using the Donabedian Principle of problem identification, process establishment, and outcome measure, was created resulting in a template in the EMR whereby clearance of the cervical spine (confrontational examination) in nonobtunded trauma patients was standardized for all providers. Outcomes before and after implementation of the EMR protocol were compared. The initial audit revealed that 71% of records lacked appropriate documentation. Of those with documentation, 26% simply stated "c-spine cleared" or "collar removed" with no documentation to support the clinical examination performed. This is in contrast to a 95% compliance rate following the use of the EMR protocol. Up to 80% of collars were removed within 3 hours of admission thereby reducing complications associated with c-collars. The use of the EMR allowed for the standardization of the cervical spine clearance, improved documentation, and allowed for the monitoring of compliance with evidenced-based c-spine protocols. Practice implications and lessons learned in the implementation of this successful Performance Improvement Patient Safety are also described.